Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review

Electronic health record and primary care physician self-reported quality of care: a multilevel study in China

BACKGROUND

Health information technology is one of the building blocks of a high-performing health system. However, the evidence regarding the influence of an electronic health record (EHR) on the quality of care remains mixed, especially in low- and middle-income countries.

OBJECTIVE

This study examines the association between greater EHR functionality and primary care physician self-reported quality of care.

METHODS

A total of 224 primary care physicians from 38 community health centres (CHCs) in four large Chinese cities participated in a cross-sectional survey to assess CHC care quality. Each CHC director scored their CHC's EHR functionality on the availability of ten typical features covering health information, data, results management, patient access, and clinical decision support. Data analysis utilised hierarchical linear modelling.

RESULTS

The availability of five EHR features was positively associated with physician self-reported clinical quality: share records online with providers outside the practice (β = 0.276, p = 0.04), access records online by the patient (β = 0.325, p = 0.04), alert provider of potential prescription problems (β = 0.353, p = 0.04), send the patient reminders for care (β = 0.419, p = 0.003), and list patients by diagnosis or health risk (β = 0.282, p = 0.04). However, no association was found between specific features availability or total features score and physician self-reported preventive quality.

CONCLUSIONS

This study provides evidence that the availability of EHR systems, and specific features of these systems, was positively associated with physician self-reported quality of care in these 38 CHCs. Future longitudinal studies focused on standardised quality metrics, and designed to control known confounding variables, will further inform quality improvement efforts in primary care.

The impact of the COVID-19 pandemic on the socioeconomic gradient of hypertension

The COVID-19 pandemic has brought into sharp focus the impact of socioeconomic factors on hypertension outcomes. This review examines the implications of the pandemic on the socioeconomic gradient of hypertension and explores the physiological and pathophysiological processes underlying this relationship. Changes in socioeconomic factors have disproportionately affected individuals with lower socioeconomic status, leading to adverse hypertension outcomes. The pandemic-related stressors, coupled with social isolation and disrupted daily routines, have contributed to elevated stress levels among individuals, particularly those with lower socioeconomic status. Equitable access to healthcare, enhancing health literacy and patient empowerment, and addressing social determinants of health are essential components of hypertension management strategies. By recognizing the specific challenges faced by individuals with lower socioeconomic status and implementing targeted interventions, public health efforts can help reduce the socioeconomic gradient of hypertension.

With advancement in health technology comes great responsibility - Ethical and safety considerations for using digital health technology: A narrative review

The accelerated adoption of digital health technologies in the last decades has raised important ethical and safety concerns. Despite the potency and usefulness of digital health technologies, addressing safety, and ethical considerations needs to take greater prominence. This review paper focuses on ethical and safety facets, including health technology-related risks, users' safety and well-being risks, security and privacy concerns, and risks to transparency and diminished accountability associated with the utilization of digital health technologies. In order to maximize the potential of health technology benefits, awareness of safety risks, and ethical concerns should be increased, and the use of appropriate strategies and measures should be considered.

Comparison of Clinical Decision Support Tools to Improve Pediatric Lipid Screening

OBJECTIVE

To test whether different clinical decision support tools increase clinician orders and patient completions relative to standard practice and each other.

STUDY DESIGN

A pragmatic, patient-randomized clinical trial in the electronic health record was conducted between October 2019 and April 2020 at Geisinger Health System in Pennsylvania, with 4 arms: care gap-a passive listing recommending screening; alert-a panel promoting and enabling lipid screen orders; both; and a standard practice-no guideline-based notification-control arm. Data were analyzed for 13 346 9- to 11-year-old patients seen within Geisinger primary care, cardiology, urgent care, or nutrition clinics, or who had an endocrinology visit. Principal outcomes were lipid screening orders by clinicians and completions by patients within 1 week of orders.

RESULTS

Active (care gap and/or alert) vs control arm patients were significantly more likely (P < .05) to have lipid screening tests ordered and completed, with ORs ranging from 1.67 (95% CI 1.28-2.19) to 5.73 (95% CI 4.46-7.36) for orders and 1.54 (95% CI 1.04-2.27) to 2.90 (95% CI 2.02-4.15) for completions. Alerts, with or without care gaps listed, outperformed care gaps alone on orders, with odds ratios ranging from 2.92 (95% CI 2.32-3.66) to 3.43 (95% CI 2.73-4.29).

CONCLUSIONS

Electronic alerts can increase lipid screening orders and completions, suggesting clinical decision support can improve guideline-concordant screening. The study also highlights electronic record-based patient randomization as a way to determine relative effectiveness of support tools.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04118348.

Management of Rheumatoid Arthritis in Primary Care: A Scoping Review

Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.

Machine learning data sources in pediatric sleep research: assessing racial/ethnic differences in electronic health record-based clinical notes prior to model training

Introduction

Pediatric sleep problems can be detected across racial/ethnic subpopulations in primary care settings. However, the electronic health record (EHR) data documentation that describes patients' sleep problems may be inherently biased due to both historical biases and informed presence. This study assessed racial/ethnic differences in natural language processing (NLP) training data (e.g., pediatric sleep-related keywords in primary care clinical notes) prior to model training.

Methods

We used a predefined keyword features set containing 178 Peds B-SATED keywords. We then queried all the clinical notes from patients seen in pediatric primary care between the ages of 5 and 18 from January 2018 to December 2021. A least absolute shrinkage and selection operator (LASSO) regression model was used to investigate whether there were racial/ethnic differences in the documentation of Peds B-SATED keywords. Then, mixed-effects logistic regression was used to determine whether the odds of the presence of global Peds B-SATED dimensions also differed across racial/ethnic subpopulations.

Results

Using both LASSO and multilevel modeling approaches, the current study found that there were racial/ethnic differences in providers' documentation of Peds B-SATED keywords and global dimensions. In addition, the most frequently documented Peds B-SATED keyword rankings qualitatively differed across racial/ethnic subpopulations.

Conclusion

This study revealed providers' differential patterns of documenting Peds B-SATED keywords and global dimensions that may account for the under-detection of pediatric sleep problems among racial/ethnic subpopulations. In research, these findings have important implications for the equitable clinical documentation of sleep problems in pediatric primary care settings and extend prior retrospective work in pediatric sleep specialty settings.

Applications of digital health approaches for cardiometabolic diseases prevention and management in the Western Pacific region

Cardiometabolic diseases (CMDs) are the major types of non-communicable diseases, contributing to huge disease burdens in the Western Pacific region (WPR). The use of digital health (dHealth) technologies, such as wearable gadgets, mobile apps, and artificial intelligence (AI), facilitates interventions for CMDs prevention and treatment. Currently, most studies on dHealth and CMDs in WPR were conducted in a few high- and middle-income countries like Australia, China, Japan, the Republic of Korea, and New Zealand. Evidence indicated that dHealth services promoted early prevention by behavior interventions, and AI-based innovation brought automated diagnosis and clinical decision-support. dHealth brought facilitators for the doctor-patient interplay in the effectiveness, experience, and communication skills during healthcare services, with rapidly development during the pandemic of coronavirus disease 2019. In the future, the improvement of dHealth services in WPR needs to gain more policy support, enhance technology innovation and privacy protection, and perform cost-effectiveness research.

Navigating the doctor-patient-AI relationship - a mixed-methods study of physician attitudes toward artificial intelligence in primary care

BACKGROUND

Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.

METHODS

From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents.

RESULTS

Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship).

CONCLUSION

Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.

Digital Health Needs and Preferences During Pregnancy and the Postpartum Period: Mixed Methods Study

BACKGROUND

Digital health is increasingly used to meet the needs of perinatal people, with estimates of pregnancy-related internet use ranging from 90% to 97% of pregnant people. As digital health takes on greater importance during the perinatal period, it is essential that providers and developers of digital health content understand why perinatal people use these resources and the features that enhance their experience. However, gaps remain in understanding the content that is most helpful and how the platforms are navigated. Learning directly from perinatal people about their needs will help ensure alignment between perinatal needs and available content.

OBJECTIVE

This formative study aims to identify the reasons why perinatal people use digital health resources; the features of the digital health platforms that are of greatest importance to them; and how these differ by perinatal stage (pregnancy vs post partum), mental health conditions, parity, and demographics (race and ethnicity).

METHODS

This mixed methods study used interviews; surveys; and secondary data on demographic, health, and pregnancy characteristics to identify the digital health needs and preferences of pregnant and postpartum people who used the Maven digital health platform in the United States during their pregnancy or postpartum period. The interviews informed the content of the surveys and provided additional insights and examples for interpreting the survey results. The surveys were used to collect data from a sample of Maven users, and the results were linked to the secondary data set. The interviews were thematically analyzed, and survey data were analyzed using descriptive statistics and stratified by parity, race, and mental health status.

RESULTS

Overall, 13 people were interviewed (including n=4, 31% pilot interviews), and 147 pregnancy and 110 postpartum survey respondents completed the surveys and had linkable secondary data. Top reasons for using digital health resources during pregnancy were to (1) know what is normal or typical during pregnancy, (2) have access to a health care provider when needed, and (3) know how the baby is developing. Top reasons for postpartum use were to (1) help with breastfeeding, (2) know what normal baby development is, and (3) help with the baby's health issues. Top platform features during pregnancy and the postpartum period were (1) credible and trustworthy information and providers, (2) nonjudgmental information and support, and (3) no cost to the user. In general, more reasons for using digital resources were identified as extremely important during pregnancy compared with post partum. The results showed minor variations across strata.

CONCLUSIONS

This formative research found minor differences in digital resource needs and preferences across user characteristics among perinatal people in the United States. Future work should examine whether there are variations in interests within topics by user characteristics, which may provide additional opportunities to better meet user needs.

Digital Health for Oncological Care

ABSTRACT

Digital health tools extend well beyond telemedicine, holding great potential to advance oncological care. We survey digital health and provide recommendations across the health continuum, tailoring them to oncology, including prevention, detection and diagnosis, and treatment and monitoring. Within the prevention realm, we review wellness technologies, cancer screening, mental health solutions, and digital biomarkers. For detection and diagnosis, we describe existing and emerging solutions for remote patient monitoring and various means to capture digital biomarkers, the "digital exam," and "digital outcomes." Treatment and monitoring solutions include telemedicine, chatbots, and digital therapeutics, which are also explored. We also discuss a host of technology enablers that are required for successful implementation and sustainment of digital health-enabled care. Our recommendations pertain to health care systems as well as companies that work with these systems or provide care to patients directly.

Data-driven digital health technologies in the remote clinical care of diabetic foot ulcers: a scoping review

Background

The availability and effectiveness of Digital Health Technologies (DHTs) to support clinicians, empower patients, and generate economic savings for national healthcare systems are growing rapidly. Of particular promise is the capacity of DHTs to autonomously facilitate remote monitoring and treatment. Diabetic Foot Ulcers (DFUs) are characterised by high rates of infection, amputation, mortality, and healthcare costs. With clinical outcomes contingent on activities that can be readily monitored, DFUs present a promising focus for the application of remote DHTs.

Objective

This scoping review has been conducted as a first step toward ascertaining fthe data-related challenges and opportunities for the development of more comprehensive, integrated, and individualised sense/act DHTs. We review the latest developments in the application of DHTs to the remote care of DFUs. We cover the types of DHTs in development and their features, technological readiness, and scope of clinical testing.

Eligibility criteria

Only peer-reviewed original experimental and observational studies, case series and qualitative studies were included in literature searches. All reviews and manuscripts presenting pre-trial prototype technologies were excluded.

Methods

An initial search of three databases (Web of Science, MEDLINE, and Scopus) generated 1,925 English-language papers for screening. 388 papers were assessed as eligible for full-text screening by the review team. 81 manuscripts were found to meet the eligibility criteria.

Results

Only 19% of studies incorporated multiple DHTs. We categorised 56% of studies as 'Treatment-Manual', i.e. studies involving technologies aimed at treatment requiring manual data generation, and 26% as 'Prevention-Autonomous', i.e. studies of technologies generating data autonomously through wearable sensors aimed at ulcer prevention through patient behavioural change. Only 10% of studies involved more ambitious 'Treatment-Autonomous' interventions. We found that studies generally reported high levels of patient adherence and satisfaction.

Conclusions

Our findings point to a major potential role for DHTs in remote personalised medical management of DFUs. However, larger studies are required to assess their impact. Here, we see opportunities for developing much larger, more comprehensive, and integrated monitoring and decision support systems with the potential to address the disease in a more complete context by capturing and integrating data from multiple sources from subjective and objective measurements.

The effect of digital interventions on related health literacy and skills for individuals living with chronic diseases: A systematic review and meta-analysis

BACKGROUND

Chronic diseases are a leading cause of death and disease burden globally. Digital interventions could be an approach to improve patients' ability to find, evaluate, and use health information.

OBJECTIVES

The main objective was to conduct a systematic review to determine the effect of digital interventions on digital health literacy for patients living with chronic disease. Secondary objectives were to provide an overviewof the design and delivery characteristics of interventions that impact digital health literacy in people with chronic disease.

METHODS

Randomized controlled trials examining digital health literacy (and related components) for individuals with cardiovascular disease, chronic lung disease, osteoarthritis, diabetes, chronic kidney disease, and HIV were identified. This review was conducted following the PRIMSA guidelines. Certainty was assessed using GRADE and the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.1. The protocol was registered on PROSPERO (CRD42022375967).

RESULTS

9386 articles were identified and 17 articles representing 16 unique trials were included. Studies evaluated 5138 individuals with one or more chronic conditions (50% women, ages 42 ± 7-71 ± 12 years). The most targeted conditions were cancer, diabetes, cardiovascular disease, and HIV. Interventions included: skills training, websites, electronic personal health records, remote patient monitoring, and education. The effects of the interventions were related to: (i) digital health literacy, (ii) health literacy, (iii) health information skills, (iv) technology skills and access, and (v) self-management and participation in care. A meta-analysis of three studies identified the effect of digital interventions was better than usual care for eHealth literacy (1.22 [CI 0.55, 1.89], p < 0.001).

CONCLUSIONS

The evidence of the effects of digital interventions on related health literacy is limited. Existing studies reflect the heterogeneity in study design, population, and outcome measures. There is a need for further studies on the effects of digital interventions on related health literacy for individuals with chronic conditions.

Identifying violence against persons at a safety-net hospital: Evidence from the first 6 months of implementation

OBJECTIVE

To examine the prevalence and predictors of screening for violence against persons and victim service utilization within an integrated safety-net health system.

STUDY SETTING

Emergency Department (ED) at Parkland Hospital-Dallas County's largest safety-net provider of services for minority and underinsured and uninsured patients.

STUDY DESIGN

Prospective, longitudinal study during the first 6 months of a universal violence against persons screener.

DATA COLLECTION

Health records were extracted for all patients with a visit to the ED between January and July, 2021. Modeling described the patient population across screening (screened vs. not screened) and, among those screened, the results (positive vs. negative), average time spent in the ED, and referral patterns for victim services.

PRINCIPAL FINDINGS

During the study period, 65,563 unique patients with 95,555 encounters occurred. Seventy-one percent (n = 67,535) were screened for violence against persons and, of those, 2% screened positive (n = 1349). Of the patients who screened positive, 1178 (87%) were referred to and 806 (60%) received care at victim services. Implementing screening did not increase the length of stay at ED.

CONCLUSIONS

Systematic implementation of comprehensive violence screening at a safety-net system can result in robust identification and timely referrals to victim services.

Telemedicine in Primary Care: Lessons Learned About Implementing Health Care Innovations During the COVID-19 Pandemic

PURPOSE

During the COVID-19 pandemic, telemedicine emerged as an important tool in primary care. Technology and policy-related challenges, however, revealed barriers to adoption and implementation. This report describes the findings from weekly and monthly surveys of primary care clinicians regarding telemedicine during the first 2 years of the pandemic.

METHODS

From March 2020 to March 2022, we conducted electronic surveys using convenience samples obtained through social networking and crowdsourcing. Unique tokens were used to confidentially track respondents over time. A multidisciplinary team conducted quantitative and qualitative analyses to identify key concepts and trends.

RESULTS

A total of 36 surveys resulted in an average of 937 respondents per survey, representing clinicians from all 50 states and multiple specialties. Initial responses indicated general difficulties in implementing telemedicine due to poor infrastructure and reimbursement mechanisms. Over time, attitudes toward telemedicine improved and respondents considered video and telephone-based care important tools for their practice, though not a replacement for in-person care.

CONCLUSIONS

The implementation of telemedicine during COVID-19 identified barriers and opportunities for technology adoption and highlighted steps that could support primary care clinics' ability to learn, adapt, and implement technology.

Disparities in telehealth access, not willingness to use services, likely explain rural telehealth disparities

PURPOSE

Although telehealth access and utilization have increased during the pandemic, rural and low-income disparities persist. We sought to assess whether access or willingness to use telehealth differed between rural and non-rural and low-income and non-low-income adults and measure the prevalence of perceived barriers.

METHODS

We conducted a cross-sectional study using COVID-19's Unequal Racial Burden (CURB) online survey (December 17, 2020-February 17, 2021), which included 2 nationally representative cohorts of rural and low-income Black/African American, Latino, and White adults. Non-rural and non-low-income participants from the main, nationally representative sample were matched for rural versus non-rural and low-income versus non-low-income comparisons. We measured perceived telehealth access, willingness to use telehealth, and perceived telehealth barriers.

FINDINGS

Rural (38.6% vs 44.9%) and low-income adults (42.0% vs 47.4%) were less likely to report telehealth access, compared to non-rural and non-low-income counterparts. After adjustment, rural adults were still less likely to report telehealth access (adjusted prevalence ratio [aPR] = 0.89, 95% CI = 0.79-0.99); no differences were seen between low-income and non-low-income adults (aPR = 1.02, 95% CI = 0.88-1.17). The majority of adults reported willingness to use telehealth (rural = 78.4%; low-income = 79.0%), with no differences between rural and non-rural (aPR = 0.99, 95% CI = 0.92-1.08) or low-income versus non-low-income (aPR = 1.01, 95% CI = 0.91-1.13). No racial/ethnic differences were observed in willingness to use telehealth. The prevalence of perceived telehealth barriers was low, with the majority reporting no barriers (rural = 57.4%; low-income = 56.9%).

CONCLUSIONS

Lack of access (and awareness of access) is likely a primary driver of disparities in rural telehealth use. Race/ethnicity was not associated with telehealth willingness, suggesting that equal utilization is possible once granted access.

Liquid Health. Medicine in the age of surveillance capitalism

Digital health technologies transform practices, roles, and relationships in medicine. New possibilities for a ubiquitous and constant data collection and the processing of data in real-time enable more personalized health services. These technologies might also allow users to actively participate in health practices, thus potentially changing the role of patients from passive receivers of healthcare to active agents. The crucial driving force of this transformation is the implementation of data-intensive surveillance and monitoring as well as self-monitoring technologies. Some commentators use terms like revolution, democratization, and empowerment to describe the aforementioned transformation process in medicine. The public debate as well as most of the ethical discourse on digital health tends to focus on the technologies themselves, mostly ignoring the economic framework of their design and implementation. Analyzing the transformation process connected to digital health technologies needs an epistemic lens that also considers said economic framework, which I argue is surveillance capitalism. This paper introduces the concept of liquid health as such an epistemic lens. Liquid health is based on Zygmunt Bauman's framing of modernity as a process of liquefaction that dissolves traditional norms and standards, roles, and relations. By using liquid health as an epistemic lens, I aim to show how digital health technologies reshape concepts of health and illness, change the scope of the medical domain, and liquify roles and relationships that surround health and healthcare. The basic hypothesis is that although digital health technologies can lead to personalization of treatment and empowerment of users, their economic framework of surveillance capitalism may undermine these very goals. Using liquid health as a concept allows us to better understand and describe practices of health and healthcare that are shaped by digital technologies and the specific economic practices they are inseparably attached to.

Precision public-health intervention for care coordination: a real-world study

BACKGROUND

Health emergencies disproportionally affect vulnerable populations. Digital tools can help primary care providers find, and reach, the right patients.

AIM

To evaluate whether digital interventions delivered directly to GPs' clinical software were more effective at promoting primary care appointments during the COVID-19 pandemic than interventions delivered by post.

DESIGN AND SETTING

Real-world, non-randomised, interventional study involving GP practices in all Australian states.

METHOD

Intervention material was developed to promote care coordination for vulnerable older veterans during the COVID-19 pandemic, and sent to GPs either digitally to the clinical practice software system or in the post. The intervention material included patient-specific information sent to GPs to support care coordination, and education material sent via post to veterans identified in the administrative claims database. To evaluate the impact of intervention delivery modalities on outcomes, the time to first appointment with the primary GP was measured; a Cox proportional hazards model was used, adjusting for differences and accounting for pre-intervention appointment numbers.

RESULTS

The intervention took place in April 2020, during the first weeks of COVID-19 social distancing restrictions in Australia. GPs received digital messaging for 51 052 veterans and postal messaging for 26 859 veterans. The digital group was associated with earlier appointments (adjusted hazard ratio 1.38 [1.34 to 1.41]).

CONCLUSION

Data-driven digital solutions can promote care coordination at scale during national emergencies, opening up new perspectives for precision public-health initiatives.

Digital health interventions and quality of home-based primary care for older adults: A scoping review protocol

Introduction

The use of digital health interventions has expanded, particularly in home-based primary care (HBPC), following the increase in the older adult population and the need to respond to the higher demand of chronic conditions, weakness and loss of autonomy of this population. There was an even greater demand with COVID-19 and subsequent isolation/social distancing measures for this risk group. The objective of this study is to map and identify the uses and types of digital health interventions and their reported impacts on the quality of HBPC for older adults worldwide.

Methods and analysis

This is a scoping review protocol which will enable a rigorous, transparent and reliable synthesis of knowledge. The review will be developed from the theoretical perspective of Arksey and O'malley, with updates by Levac and Peters and respective collaborators based on the Joanna Briggs Institute manual, and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). Data from white literature will be extracted from multidisciplinary health databases such as: the Virtual Health Library, LILACS, MEDLINE/PubMed, Scopus, Web of Science, Cinahl and Embase; while Google Scholar will be used for gray literature. No date limit or language restrictions will be determined. The quantitative data will be analyzed through descriptive statistics and qualitative data through thematic analysis. The results will be submitted to stakeholder consultation for preliminary sharing of the study and will later be disseminated through publication in open access scientific journals, scientific events and academic and community journals. The full scoping review report will present the main impacts, challenges, opportunities and gaps found in publications related to the use of digital technologies in primary home care.

Discussion

The organization of this protocol will increase the methodological rigor, quality, transparency and accuracy of scoping reviews, reducing the risk of bias.

Can Electronic Clinical Decision Support Systems Improve the Diagnosis of Urinary Tract Infections? A Systematic Review and Meta-Analysis

Background

Urinary tract infection (UTI) is a commonly misdiagnosed infectious syndrome. Diagnostic stewardship interventions can reduce rates of asymptomatic bacteriuria treatment but are often labor intensive, and thus an automated means of reducing unnecessary urine testing is preferred. In this systematic review and meta-analysis, we sought to identify studies describing interventions utilizing clinical decision support (CDS) to optimize UTI diagnosis and to characterize the effectiveness of these interventions.

Methods

We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published before July 2, 2021. Publications describing an intervention intending to enhance UTI diagnosis via CDS were included. The primary outcome was urine culture test rate.

Results

The electronic search identified 5013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion, and a manual reference list review identified 5 additional studies, yielding a total of 14 studies included in the systematic review. The most common CDS intervention was urinalysis with reflex to urine culture based on prespecified urinalysis parameters. All 9 studies that provided statistical comparisons reported a decreased urine culture rate postintervention, 8 of which were statistically significant. A meta-analysis including 4 studies identified a pooled urine culture incidence rate ratio of 0.56 (95% confidence interval, .52-.60) favoring the postintervention versus preintervention group.

Conclusions

In this systematic review and meta-analysis, CDS appeared to be effective in decreasing urine culture rates. Prospective trials are needed to confirm these findings and to evaluate their impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects.

Economic Evaluation of Pharmacist-Led Digital Health Interventions: A Systematic Review

There has been growing interest in integrating digital technologies in healthcare. The purpose of this study was to systematically review the economic value of pharmacist-led digital interventions. PubMed, Web of Science, and the Cochrane databases were searched to select studies that had conducted economic evaluations of digital interventions by pharmacists for the period from January 2001 to February 2022. Economic evidence from 14 selected studies was synthesized in our analysis. Pharmacists used telephones, computers, web-based interventions, videotapes, smartphones, and multiple technologies for their digital interventions. Prior studies have reported the results of telephone-based interventions to be cost-effective. Alternatively, these interventions were found to be cost-effective when reevaluated with recently cited willingness-to-pay thresholds. In addition, pharmacist-led interventions based on computers, web-based interventions, smartphones, and multiple technologies have been reported to be cost-effective in previous studies. However, videotape-based intervention was found cost-ineffective because there was no significant difference in outcomes between the intervention and the usual care groups. If this intervention had been intensive enough to improve outcomes in the intervention group, favorable cost-effectiveness results could have been obtained. The economic evidence in the previous studies represented short-term economic values. Economic evaluations of the long-term value of digital interventions are warranted in future studies.

Evaluation Methods Applied to Digital Health Interventions: What Is Being Used beyond Randomised Controlled Trials?-A Scoping Review

Despite the potential of digital health interventions (DHIs), evaluations of their effectiveness face challenges. DHIs are complex interventions and currently established evaluation methods, e.g., the randomised controlled trial (RCT), are limited in their application. This study aimed at identifying alternatives to RCTs as potentially more appropriate evaluation approaches. A scoping review was conducted to provide an overview of existing evaluation methods of DHIs beyond the RCT. Cochrane Central Register of Controlled Trials, MEDLINE, Web of Science, and EMBASE were screened in May 2021 to identify relevant publications, while using defined inclusion and exclusion criteria. Eight studies were extracted for a synthesis comprising four alternative evaluation designs. Factorial designs were mostly used to evaluate DHIs followed by stepped-wedge designs, sequential multiple assignment randomised trials (SMARTs), and micro randomised trials (MRTs). Some of these methods allow for the adaptation of interventions (e.g., SMART or MRT) and the evaluation of specific components of interventions (e.g., factorial designs). Thus, they are appropriate for addressing some specific needs in the evaluation of DHIs. However, it remains unsolved how to establish these alternative evaluation designs in research practice and how to deal with the limitations of the designs.